Left Lung Mass Research Articles

7917 Bilateral Adrenal Hemorrhages As The Initial Presentation Of Poorly Differentiated Bronchogenic Carcinoma

Abstract Disclosure: B. Malapur: None. M.G. Jakoby: None. V. Williams: None. Introduction: Bilateral adrenal hemorrhage is rare, and most cases occur in the setting of bacterial sepsis, coagulopathies such as antiphospholipid antibody syndrome, treatment with anticoagulants, surgery, or trauma. We present a patient with asynchronous bilateral adrenal hemorrhages that resulted in an eventual diagnosis of poorly differentiated bronchogenic carcinoma. Case: A 65-year-old female smoker was found to have a large right adrenal hematoma on computed tomography (CT) obtained for evaluation of acute onset right flank pain. No hemorrhage or anatomic abnormalities of the left adrenal gland were apparent, and the patient was discharged home after her pain was controlled. Approximately one month later, she returned to hospital with bilateral flank pain, and bilateral adrenal hemorrhages were diagnosed on repeat CT imaging. An 8 cm left upper lobe lung mass was revealed on a chest CT scan, and cytology from a bronchoscopic biopsy confirmed poorly differentiated bronchogenic carcinoma. The patient had no recent surgeries, abdominal trauma, or treatment with anticoagulants, serologic evaluation for coagulopathies and disseminated intravascular coagulation was unremarkable, blood cultures failed to grow bacterial pathogens, and acid-fast staining of lung tissue was negative. The patient was discharged from her second hospital admission on hydrocortisone and fludrocortisone. Discussion: Adrenal hemorrhage in the setting of malignancy is usually a complication of adrenal metastases. The prevalence of adrenal metastases in advanced stage cancer is approximately 3%, with lung and breast cancers and melanoma showing the highest predilection for adrenal metastases. This case is unusual because the patient had no focal masses or disruption of left adrenal contour on CT to indicate adrenal metastases at the time of right adrenal hemorrhage, and she did not have other established risk factors for pathologic bleeding in the setting of malignancy such as thrombocytopenia or treatment with chemotherapy agents, anticoagulants, or nonsteroidal anti-inflammatory drugs. Adrenal hemorrhage is also a rare inciting event resulting in the diagnosis of lung cancer; to date, there are only 29 published cases of spontaneous adrenal hemorrhage as the initial presentation of lung cancer. This case illustrates the importance of careful evaluation for malignancy in patients with spontaneous adrenal hemorrhage and no clear etiology for adrenal bleeding. Presentation: 6/1/2024

Pancoast Syndrome Due to Metastatic Hepatocellular Carcinoma

Pancoast tumors are aggressive and locally invasive apical lung cancers that often compress and infiltrate adjacent structures including the brachial plexus, stellate ganglion, ribs, and vertebral bodies. Symptoms of Pancoast tumors include Pancoast Syndrome, characterized by Horner Syndrome and pain and weakness of the ipsilateral upper extremity. Pancoast tumors by definition are primary lung cancer and are nearly always non-small cell lung cancer (NSCLC). There are rare case reports of metastatic non-pulmonary malignancies forming apical lung tumors mimicking Pancoast tumors and causing Pancoast Syndrome. Here, we present a case of a 66-year-old male with a history of unresectable hepatocellular carcinoma (HCC) who presented with one year of progressive left wrist and forearm pain and hand weakness and was found on cross-sectional imaging to have a left upper lobe lung mass invading the T1 and T2 vertebral bodies. Pathology showed very poorly differentiated carcinoma that required specialized testing to achieve diagnostic clarity. The tumor was positive for albumin mRNA, which aided in confirming the lung mass as metastatic HCC. This case highlights a rare incidence of Pancoast Syndrome due to metastatic HCC and emphasizes the importance of considering this diagnosis as an etiology of left upper extremity pain in a patient with previously diagnosed malignancy. This case also demonstrates the utility of albumin mRNA in-situ hybridization as an additional tool in identifying metastatic HCC and reviews general principles of symptomatic management of Pancoast Syndrome.

18 F-FAPI for Imaging Metastatic Perivascular Epithelioid Cell Neoplasm.

We compared 18 F-FAPI and 18 F-FDG PET/CT findings of metastatic perivacular epitheliod cell tumor in a 23-year-old woman. Apart from showing strong uptake of a left upper lung mass that showed moderate uptake on 18 F-FDG, 18 F-FAPI PET/CT additionally presented hypermetabolism in diffuse multifocal lesion throughout the body. This case suggests that 18 F-FAPI PET/CT might play a more beneficial role than 18 F-FDG PET/CT in identifying and assessing the extent of perivascular epithelioid cell tumors.

Pulmonary actinomycosis mimicking lung cancer – a case report

We present a case of a 55-year-old female patient admitted to the Thoracic Surgery Center for the treatment of a solid left lung mass of unknown aetiology. The patient was transported from another hospital, and the main reason for the patient’s referral to the Thoracic Surgery Center was recurrent haemoptysis and pulmonary haemorrhages. A chest X-ray in the posteroanterior projection showed no changes that could indicate the cause of the patient’s symptoms. In the course of diagnosis, a positron emission tomography combined with computed tomography scan was performed, in which an area of pathological radiotracer uptake was detected in the X segment of the left lung, with transverse dimensions of 6 × 6.5 cm, suggesting left lung cancer. Lower left lung lobectomy was performed, along with mediastinal lymphadenectomy. Final diagnosis was reached by histopathological examination of the resected tissues – the image corresponded to pulmonary actinomycosis.

Primary Pulmonary Diffuse Large B-Cell Lymphoma - a Rare Case Report

Background: Diffuse large B cell lymphoma (DLBCL) is an aggressive hematological malignancy, and a common histological form of non-Hodgkin's lymphoma. However, its extra-nodal presentation is seen in 30-40% of cases with involvement of gastrointestinal tract, skin, testes, adrenals and bone. ( Lugogo NL et al., 2006) A pulmonary manifestation is an extremely rare entity. We present an atypical case of DLBCL presenting as pleuritic chest pain with imaging consistent with bilateral pulmonary nodules suggestive of metastasis. Case description: A healthy 87 year old male former smoker with a history of type 2 diabetes mellitus, hypertension presented to the emergency department with pleuritic chest pain. There was no associated cough, shortness of breath, palpitations, nausea, dizziness or diaphoresis. No recent infections or B symptoms. He had a good appetite. He had prostate cancer 20 years ago and had a radical prostatectomy. Upon presentation, work up showed mild anemia (Hb 11.1 g/dL). Cardiac work up for chest pain was unremarkable. Chest X-Ray revealed mass like opacities in each lung with largest in left mid lung measuring up to 6 cm. CT chest with IV contrast revealed multiple lung nodules bilaterally with 2 largest in left upper lobe measuring 5.6 x 3.7 cm and 5.7 x 3.3 cm. Multiple other small nodules are present in both lung fields consistent with diffuse lung metastasis. No lymphadenopathy was noted. (Image 1) PET CT scan was significant for bilateral FDG avid lung lesions. No evidence of other FDG avid disease. CT guided biopsy of the left lung mass surprisingly revealed diffuse large B cell non-Hodgkin's lymphoma, non-germinal center type. (Image 1) Immuno-histochemistry showed atypical lymphocytes positively stained with CD20, BCL6, BCL2, PAX5 and MUM1. C-myc had 50% positivity. Ki67 had 90% proliferative index. FISH analysis was negative for MYC, BCL2 and BCL6; hence there was no double hit lymphoma detected. According to Lunago classification, patient had advanced stage disease with IPI (prognosis index) of 2. His ECOG PS score was 0. He was initiated on R-Pola-CHP. Given his age, Cyclophosphamide and Adriamycin doses were reduced as done with R-mini CHOP. Vincristine was avoided given neurotoxicity. Discussion: Primary pulmonary B-cell lymphomas (PP-BCLs) represent less than 3-4% of all extra-nodal NHL. They primarily affect the lung without evidence of extrapulmonary disease at the time of diagnosis. PP-DLBCL accounts for only 10% cases of PP-BCLs. ( Sanguedolce et al., 2021) Most cases have atypical presentation. Likewise, in our patient, he manifested with atypical chest pain without any B symptoms. Radiographic imaging can show variable findings of consolidation, single/multiple nodules, reticular interstitial infiltrate or bilateral ground glass opacities. In view of the insidious onset and lack of specificity in clinical symptoms, primary pulmonary lymphomas are frequently misdiagnosed as refractory pneumonia, lung abscess, asthma, primary lung cancer, or lung metastasis. ( Liu et al., 2020) Patients with DLBCL are typically treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone). However, with this regimen, only 60% of patients are cured and the rest might relapse. In the POLARIX phase 3 trial, polatuzumab vedotin (a monoclonal antibody to CD79b ubiquitously expressed on B cells) combined with R-CHP significantly improved 2 year progression-free survival compared to the routine R-CHOP therapy in previously untreated DLBCL patients. ( Tilly et al., 2022) Given our patient's advanced stage disease, he was initiated on the Pola-R-CHP regimen. Doses of cyclophosphamide and doxorubicin were reduced as per the R-mini CHOP dose-reduced regimen for a physically fit elderly individual. Patient continues on therapy at the time of this abstract. In conclusion, primary pulmonary DLBCL is a rare entity with only a few case reports in literature. It should be considered in patients presenting with large pulmonary masses, mimicking metastatic disease.

Evaluation of regional lung mass and growth in neonates with bronchopulmonary dysplasia using ultrashort echo time magnetic resonance imaging.

Bronchopulmonary dysplasia (BPD) is the most common long term pulmonary morbidity in premature infants and is characterized by impaired lung growth and development. We hypothesized that lung mass growth is a critical factor in determining outcomes in infants with BPD. To measure regional lung density and mass in infants with BPD and compare to clinical variables. We conducted a retrospective cohort study of neonates (n = 5 controls, n = 46 with BPD). Lung mass and lung density were calculated using ultrashort echo time (UTE) magnetic resonance imaging (MRI). Lung mass increased with increasing corrected gestational age at the time of MRI in all patients. Total, right, and left lung mass in infants with BPD trended higher than control infants (65.7 vs. 49.9 g, 36.2 vs. 26.8 g, 29.5 vs. 23.1 g, respectively). Babies with BPD who survived to discharge had higher relative lung mass than control infants and infants with BPD that did not survive to discharge (21.6 vs. 15.7 g/kg, p = .01). There was a significant association between the rate of lung mass growth and linear growth at the time of MRI (p = .034). Infants with BPD are capable of building lung mass over time. While this lung mass growth in infants with BPD may not represent fully functional lung tissue, higher lung mass growth is associated with increased linear growth.

Testicular metastasis 9 years after resection of primary descending colon cancer with simultaneous pulmonary metastasis: a case report

BackgroundMetastatic testicular cancer is rare. In particular, primary colorectal cancer rarely metastasizes to the testes. This study reports a case of testicular metastasis recurrence 9 years after the resection of a primary colorectal cancer and a simultaneous metastatic lung tumour.Case presentationA 69-year-old man underwent a laparoscopic left hemicolectomy for descending colon cancer. Preoperative computed tomography revealed a solitary left lung mass. Postoperative chemotherapy reduced the size of the lung mass, and 6 months after the primary resection, the patient underwent a left upper segmentectomy. Based on the pathological examination, he was diagnosed with pulmonary metastasis from colorectal cancer. After four courses of adjuvant chemotherapy, the patient was recurrence-free. However, 9 years and 6 months after the primary resection, he complained of discomfort in his left testicle. Physical examination revealed a left testicular mass. Since a malignancy was not excluded via imaging, left testicular resection was performed to confirm the diagnosis. The pathological diagnosis was testicular metastasis from colorectal cancer. The patient was followed up without medication, and remained healthy, without recurrence, 11 months postoperatively.ConclusionsIt is important to follow up with testicular metastasis in mind, although it is rare.

Colorectal cancer metastases in thyroid: case report and literature review

BackgroundThe thyroid gland is an uncommon site for metastatic deposits from non-thyroid malignancies, occurring in only 1.4 - 3% of surgical specimens where malignancy is suspected. It is even rarer for the source of thyroid metastases to be of colorectal origin. In most cases reported, colorectal metastases in the thyroid occurs many years later after the primary colorectal cancer has been diagnosed and treated. In this unique case, a primary sigmoid carcinoma metastasised to the thyroid gland and presented synchronously as a thyroid nodule.Case presentationWe describe a case of a 64-year-old Caucasian woman who presented with clinical features of metastatic cancer of unknown origin. Her medical history included underlying hyperthyroidism. She had a large pelvic mass adjacent to the sigmoid colon, a left lower lobe lung mass and a suspicious nodule in the left thyroid lobe. A fine-needle aspiration biopsy of the thyroid nodule was performed, which remarkably showed malignant cells originating from primary colorectal cancer on immunohistochemical staining. The patient was managed with palliative chemotherapy given the poor prognosis due to disseminated colorectal malignancy.ConclusionsColorectal adenocarcinoma metastases can rarely present as a metastatic thyroid nodule. Fine-needle aspiration should be performed in suspicious thyroid nodules and may be the least invasive way of identifying a metastatic colorectal or other non-thyroidal malignancy in patients presenting with an unknown primary. The pathologist should be vigilant to this possibility and specific immunohistochemical markers should be used to ensure accurate diagnosis.In thyroid metastases, the prognosis is ultimately determined by the primary tumour but thyroidectomy still has a role in alleviating compressive symptoms and can potentially improve survival in selected cases.

A Systematic Review of Lung Autopsy Findings in Elderly Patients after SARS-CoV-2 Infection.

Although COVID-19 may cause various and multiorgan diseases, few research studies have examined the postmortem pathological findings of SARS-CoV-2-infected individuals who died. Active autopsy results may be crucial for understanding how COVID-19 infection operates and preventing severe effects. In contrast to younger persons, however, the patient's age, lifestyle, and concomitant comorbidities might alter the morpho-pathological aspects of the damaged lungs. Through a systematic analysis of the available literature until December 2022, we aimed to provide a thorough picture of the histopathological characteristics of the lungs in patients older than 70 years who died of COVID-19. A thorough search was conducted on three electronic databases (PubMed, Scopus, and Web of Science), including 18 studies and a total of 478 autopsies performed. It was observed that the average age of patients was 75.6 years, of which 65.4% were men. COPD was identified in an average of 16.7% of all patients. Autopsy findings indicated significantly heavier lungs, with an average weight of the right lung of 1103 g, while the left lung mass had an average weight of 848 g. Diffuse alveolar damage was a main finding in 67.2% of all autopsies, while pulmonary edema had a prevalence of between 50% and 70%. Thrombosis was also a significant finding, while some studies described focal and extensive pulmonary infarctions in 72.7% of elderly patients. Pneumonia and bronchopneumonia were observed, with a prevalence ranging from 47.6% to 89.5%. Other important findings described in less detail comprise hyaline membranes, the proliferation of pneumocytes and fibroblasts, extensive suppurative bronchopneumonic infiltrates, intra-alveolar edema, thickened alveolar septa, desquamation of pneumocytes, alveolar infiltrates, multinucleated giant cells, and intranuclear inclusion bodies. These findings should be corroborated with children's and adults' autopsies. Postmortem examination as a technique for studying the microscopic and macroscopic features of the lungs might lead to a better knowledge of COVID-19 pathogenesis, diagnosis, and treatment, hence enhancing elderly patient care.

38. Who's driving treatment? Two co-occurring driver mutations in Primary Lung Adenocarcinoma

Oncogenic driver mutations in NSCLC have been historically thought to be mutually exclusive. Tumors with co-occurring mutations are part of a rare molecular subtype with no defined targeted therapies. We report a 78-year-old Caucasian female with a history of smoking, presenting to the ER with dyspnea on exertion, intermittent cough, and chest wall discomfort. PET CT imaging revealed large bilateral hypermetabolic areas of mass-like consolidation throughout the lungs. A CT-guided left lung mass core biopsy demonstrated adenocarcinoma with acinar and micropapillary patterns. TTF-1 was positive and is consistent with a lung primary. NGS analysis detected a KRAS c.38G>A p.(G13D) mutation and a co-occurring class II BRAF c.1391G>T p.(G464V) mutation. EGFR testing, ALK and ROS1 FISH were negative and PD-L1 expression was positive. Interestingly, of the few reported co-occurring KRAS and BRAF mutation cases, all have BRAF non-V600E mutations. Class II BRAF cases have been reported to be insensitive to anti-BRAF targeted therapy and almost all KRAS mutations, except G12C, do not have a targeted therapy. However, it has been suggested that specific KRAS mutations are better candidates for immunotherapy and currently there is an mRNA vaccine being considered for KRAS mutations including G13D. Our patient has begun the first cycle of chemotherapy plus immunotherapy consisting of carboplatin + pemetrexed + pembrolizumab based on the PD-L1 expression. To the best of our knowledge, although KRAS and BRAF co-mutations have been previously described, this is the first report of these specific mutations observed together in NSCLC. Oncogenic driver mutations in NSCLC have been historically thought to be mutually exclusive. Tumors with co-occurring mutations are part of a rare molecular subtype with no defined targeted therapies. We report a 78-year-old Caucasian female with a history of smoking, presenting to the ER with dyspnea on exertion, intermittent cough, and chest wall discomfort. PET CT imaging revealed large bilateral hypermetabolic areas of mass-like consolidation throughout the lungs. A CT-guided left lung mass core biopsy demonstrated adenocarcinoma with acinar and micropapillary patterns. TTF-1 was positive and is consistent with a lung primary. NGS analysis detected a KRAS c.38G>A p.(G13D) mutation and a co-occurring class II BRAF c.1391G>T p.(G464V) mutation. EGFR testing, ALK and ROS1 FISH were negative and PD-L1 expression was positive. Interestingly, of the few reported co-occurring KRAS and BRAF mutation cases, all have BRAF non-V600E mutations. Class II BRAF cases have been reported to be insensitive to anti-BRAF targeted therapy and almost all KRAS mutations, except G12C, do not have a targeted therapy. However, it has been suggested that specific KRAS mutations are better candidates for immunotherapy and currently there is an mRNA vaccine being considered for KRAS mutations including G13D. Our patient has begun the first cycle of chemotherapy plus immunotherapy consisting of carboplatin + pemetrexed + pembrolizumab based on the PD-L1 expression. To the best of our knowledge, although KRAS and BRAF co-mutations have been previously described, this is the first report of these specific mutations observed together in NSCLC.

UTILIZATION OF CONTINUOUS REMOTE MONITORING FOR A HIGH-RISK PATIENT REQUIRING INTERVAL TUMOR DEBULKING PALLIATIVE THERAPY

UTILIZATION OF CONTINUOUS REMOTE MONITORING FOR A HIGH-RISK PATIENT REQUIRING INTERVAL TUMOR DEBULKING PALLIATIVE THERAPY

AN INCIDENTAL FINDING OF ASYMPTOMATIC PULMONARY MUCORMYCOSIS IN A PATIENT WITH DIABETES

AN INCIDENTAL FINDING OF ASYMPTOMATIC PULMONARY MUCORMYCOSIS IN A PATIENT WITH DIABETES

IGG4-RELATED DISEASE PRESENTING AS A PULMONARY INFLAMMATORY PSEUDOTUMOR

IGG4-RELATED DISEASE PRESENTING AS A PULMONARY INFLAMMATORY PSEUDOTUMOR

A Rare Case of Chylothorax Manifestation of Gorham’s Disease, Lymphangioma and Tuberculosis

Background: Chylothorax is a rare condition caused by accumulation of chyle in the pleural cavity (2-3%). More rare causes are Gorham's disease and tuberculosis
 Case: A 31-year-old male complained of swelling left arm and shortness of breath with recurrent pleural effusion. Pleural fluid analysis showed chylous. Bone survey showed osteolytic lesions of multiple bones as Gorham's disease. Thoracic CT showed left lung mass, atelectasis, massive fluidothorax, ipsilateral supraclavicular lymphadenopathy, destructive left scapula. Needleaspiration of left humerus revealed lymphangioma. Expert Mtb-Rif examination revealed Mtb detected. We assessed Gorham'sdisease, lymphangioma and lung tuberculosis with complication recurrent chylothorax and was treated anti-tuberculosis, anti-osteolytic and thorax catheter insertion.
 Conclusion: Difficult and rare case of chylothorax in one patient with Gorham’s disease and tuberculosis, is a poor prognosis.
 Keywords: Chylothorax, Gorham's Disease, Tuberculosis

Autopsy case of a patient with rapidly progressive combined small‐cell lung carcinoma with spindle‐shaped cell tumor

A 69‐year‐old Japanese man visited our hospital because of worsening shortness of breath. His chest computed tomography (CT) showed a giant left lung mass with a massive left pleural effusion. He could not be treated with chemotherapy and eventually died from a rapidly progressive tumor. He was diagnosed with combined small cell lung carcinoma (C‐SCLC) with spindle‐shaped cell tumor at autopsy. C‐SCLC is characterized by pathologically concurrent SCLC and adenocarcinoma or squamous cell carcinoma, or rarely, spindle‐shaped cell tumor. The clinical course of C‐SCLC with spindle‐shaped cell tumor has not previously been determined. Our patient's tumor increased by 2.59‐fold in 20 days. The combination of C‐SCLC with spindle‐shaped cell tumor suggested rapid progression and a poor prognosis.

Abstract 3343: Durable response to osimertinib monotherapy as first line treatment in stage IVB lung adenocarcinoma with atypical EGFR L747P mutation

Abstract Background: Targeted therapy plays a critical role in NSCLC with a certain type of mutation. Osimertinib is a third generation EGFR tylosine kinase inhibitor (TKI) which is primarily indicated for NSCLC with EGFR exon 19 deletions or exon 21 L858R mutations. Although use of osimertinib is currently limited to patients with common EGFR mutations, it has been reported that patients with NSCLC harboring uncommon EGFR mutations demonstrated response to EGFR TKIs. Herein, we present a case of advanced adenocarcinoma of the lung with atypical EGFR L747P mutation that revealed a noteworthy durable response to osimertinib monotherapy as first line treatment. Case presentation: A 47-year-old woman with no smoking history presented with new-onset hemoptysis and cough. A chest CT scan showed a lobulated, spiculated 38 mm left upper lung mass with innumerable bilateral pulmonary nodules. CT-guided biopsy demonstrated adenocarcinoma of lung with PD-L1 1-2%. Subsequent PET-CT scan revealed hypermetabolic neoplasm in the left lower lobe with scattered area of abnormal focal FDG uptake within the liver. Brain MRI showed unremarkable findings. The patient was diagnosed with stage IVB adenocarcinoma of lung with multiple hepatic metastases. Circulating tumor DNA (ctDNA) NGS assay showed EGFR L747P [0.3% of variant allele frequency (VAF)] and tissue NGS assay revealed EGFR L747P missense variant c.2239_2240delinsCC (22.8% of VAF). The patient was started on osimertinib 80 mg daily. Follow up CT scan in six week demonstrated decrease in size of the left lower lobe lung mass to 32 mm. She has maintained durable SD for six months without any adverse effects. Most recent follow-up CT scan after eight months from the treatment demonstrated SD of the mass in the left lower lobe and less prominent numerous pulmonary nodules. Discussion: It has not been reported that osimertinib monotherapy is used as first line therapy in NSCLC with EGFR L747P mutation. We report the case of durable response to osimertinib in patients with advanced NSCLC with EGFR L747P mutation. Our case highlights the potential efficacy of osimertinib to NSCLC with atypical EGFR mutation. Although there was a clinical trial to explore clinical activity of osimertinib in patients with NSCLC harboring uncommon EGFR mutation, EGFR L747R mutation was not investigated at that time. To date, there are no ongoing clinical trials on the use of osimertinib in NSCLC with EGFR L747P mutation. Further investigations are warranted to confirm the efficacy of osimertinib in this type of mutation. Citation Format: Horyun Choi, Yeun Ho Lee, Jinah Kim, Leeseul Kim, Na Hyun Kim, Young Kwang Chae. Durable response to osimertinib monotherapy as first line treatment in stage IVB lung adenocarcinoma with atypical EGFR L747P mutation [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3343.

S3505 The Fall

Introduction: In December 2019, a novel virus emerged in China (COVID-19) affecting the way we practice medicine. Colorectal cancer screening and surveillance, via colonoscopy, had to be postponed in order to diminish risks of exposure. In this case we will illustrate the effects of delayed CRC screening, and how a lucky fall played a part in diagnosing our patient’s rectal cancer. Case Description/Methods: A 71-year-old man with history of chronic tobacco abuse, presented to the ER for evaluation after falling down a flight of stairs. On ROS, he denied any alarm symptoms, except for weakness. Physical examination identified a malnourished individual, with pain on his left arm. CT was remarkable for left humeral fracture and a left sided pulmonary mass. PET scan revealed two avid lesions, one consistent with a left lung mass and another at distal rectum (Figure 1, Panel A). Colonoscopy with EUS was done, results are seen in Figure 1, Panel B. Biopsy of rectal mass was consistent with rectal adenocarcinoma (Figure 1, Panel B, C). Lung mass biopsy revealed an adenocarcinoma whose primary origin was unknown. Tumor board discussions culminated with recommendations to repeat core needle biopsy of lung. Immunohistochemistry aided in his final diagnosis of stage IV CRC (Figure 1, Panel D,E). Treatment was supportive and he was discharged home. Discussion: Our patient is a prime example of how the pandemic has dramatically changed the way we practice medicine. Not having undergone a colonoscopy in his life, a fortuitous fall became the most vital symptom in his rectal cancer diagnosis. He did not have typical alarm symptoms, yet he presented with sarcopenia and gradual weakness. While minimizing risks of exposure, imaging was vital for our patient. Nontheless, EUS and core needle biopsy were ultimately needed to distinguish multiple primary tumors from stage IV rectal cancer. Amid the pandemic, short-course chemoradiotherapy and brachytherapy may be an acceptable treatment plan. Undoubtedly, the impact of COVID-19 on colorectal screening and surveillance has been great. This virus has seriously altered modern medical practice; however, maintaining our goal of protecting patients, we rose to the occasion.Figure 1.: A. Hypermetabolic process on the walls of the distal rectum. B. Large friable mass at rectum with perirectal tissue/prostate gland/anal canal infiltration. C, D. Rectal pathology: Superficially invasive, well differentiated adenocarcinoma. E,F. Lung pathology: Cytology consistent with adenocarcinoma, CDX-2 positive, Napsin-A negative.

SOLITARY FIBROUS SARCOMA: LATE PRESENTATION WITH DIRE EFFECTS

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: A 73-year-old woman with history of breast cancer status post radiation and chemotherapy was eval-uated in our emergency department (ED) for left sided chest pain that worsened over the previous month. She had two weeks of progressive physical limitation, and developed orthopnea the night prior which prompted her to seek care. CASE PRESENTATION: In the ED she was noted to have unrelenting left sided pleuritic chest pain. Physical exam was nota-ble for diminished breath sounds on the left side. Computed tomography (CT) scan of her chest re-vealed a 9.7 x 5.5 cm left lung mass with an associated complex loculated effusion. A left sided chest tube was placed for the loculated pleural effusion. It was exudative by Light's criteria, and pleural flu-id hematocrit was consistent with a hemothorax. She underwent a biopsy of the left lung mass which demonstrated CD34, BCL2, STAT6, spindle cell features and staghorn vasculature indicating a ma-lignant solitary fibrous sarcoma (SFS). She eventually underwent resection as an outpatient once staging confirmed no distant metastatic disease. DISCUSSION: The majority of thoracic solitary fibrous tumors (SFTs) are asymptomatic benign intrathoracic masses discovered incidentally on chest imaging. SFS are a malignant subtype of SFT [1]. Our case demon-strates a rare finding of a large left sided malignant solitary fibrous sarcoma that presented with a large hemothorax. SFTs generally arise from CD34+ dendritic mesenchymal cells which are present in nearly all connective tissues [2]. Association with pleural effusion may be associated with an in-creased risk of a malignant tumor [3]. The presence of a hemothorax has also been reported to cor-relate with rapid tumor enlargement [3]. STAT6, CD34, BCL2 are the most commonly found positive markers, with STAT6 sensitivity being reported as high as 100% [4]. CONCLUSIONS: Our patient did have a history of radiation treatment for left sided breast cancer which has been im-plicated in the development of SFS, particularly in the same radiation fields [5, 6]. Prognosis is usual-ly unpredictable with surgery being the gold standard in treatment [7]. In malignant tumors, chemo-therapy and radiation have limited efficacy [7]. Recurrence rates in malignant SFS are high even with complete resection, reported to be around 63% [8]. REFERENCE #1: Davanzo B, Emerson RE, Lisy M, Koniaris LG, Kays JK. Solitary fibrous tumor. Transl Gastroente-rol Hepatol. 2018 Nov 21;3:94. doi: 10.21037/tgh.2018.11.02. PMID: 30603730; PMCID: PMC6286917. REFERENCE #2: Zuo Z, Zhou H, Sun Y, Mao Q, Zhang Y, Gao X. Rapidly growing solitary fibrous tumors of the pleura: a case report and review of the literature. Ann Transl Med. 2020 Jul;8(14):890. doi: 10.21037/atm-20-4974. PMID: 32793734; PMCID: PMC7396790. REFERENCE #3: Tan JH, Hsu AA. Challenges in diagnosis and management of giant solitary fibrous tumour of pleu-ra: a case report. BMC Pulm Med 2016;16:114. 10.1186/s12890-016-0279-0. REFERENCE #4: Zhang P, Xiong K, Lv P, et al. Malignant solitary fibrous tumor occurring in the mediastinal pleura showing NAB2ex4-STAT6ex2 fusion and negative STAT6 immunohistochemistry: A case report. Thorac Cancer 2020;11:1344-9. 10.1111/1759-7714.13395. REFERENCE #5: Rubino C, Shamsaldin A, Lê MG, Labbé M, Guinebretière JM, Chavaudra J, de Vathaire F. Radia-tion dose and risk of soft tissue and bone sarcoma after breast cancer treatment. Breast Cancer Res Treat. 2005;89(3):277–288. doi: 10.1007/s10549-004-2472-8. REFERENCE #6: Karlsson P, Holmberg E, Johansson KA, Kindblom LG, Carstensen J, Wallgren A. Soft tissue sar-coma after treatment for breast cancer. Radiother Oncol. 1996;38(1):25–31. doi: 10.1016/0167-8140(95)01663-5. REFERENCE #7: Ronchi et al., "Extrapleural Solitary Fibrous Tumor: A Distinct Entity from Pleural Solitary Fibrous Tumor. An Update on Clinical, Molecular and Diagnostic Features. REFERENCE #8: Boothe JT, Budd GT, Smolkin MB, et al. Durable Near-Complete Response to Anti-PD-1 Check-point Immunotherapy in a Refractory Malignant Solitary Fibrous Tumor of the Pleura. Case Rep Oncol 2017;10:998-1005. 10.1159/000484041. DISCLOSURES: No relevant relationships by Danish Ahmad, source=Web Response No relevant relationships by Saad Ashraf, source=Web Response No relevant relationships by Fiyad Haniff, source=Web Response no disclosure on file for Jennifer Toth

A TICKING TIMEBOMB: FLOATING AORTIC ARCH THROMBUS IN A PATIENT WITH METASTATIC SQUAMOUS CELL CARCINOMA OF THE LUNG

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Thoracic aortic mural thrombi are a rare clinical entity and most patients are asymptomatic before significant embolic events occur(1). There are only a few reported cases and are mostly in patients who presented with complications of peripheral thromboembolism. We report the case of a patient who presented with symptoms of congestive heart failure and was found to have a large floating thoracic aortic thrombus. CASE PRESENTATION: The patient is a 61-year-old female with no prior medical history who presented with shortness of breath on exertion and dry cough of three weeks duration. The patient has an extensive 40 pack-year smoking history. On evaluation, the patient was tachypneic, hypertensive, and was saturating well on room air. Crackles could be heard at the bases of the lungs and there was pitting edema of bilateral lower extremities. Laboratory studies showed a b-type natriuretic peptide level of 1741 pg/mL. A chest X-ray revealed pulmonary edema and bilateral pleural effusions. With a diagnosis of heart failure, gentle diuresis with intravenous furosemide was initiated. An echocardiogram showed global hypokinesis of the left ventricle with a reduced ejection fraction of 25-30%. CT scan of the chest revealed a large 6 x 7 cm necrotic mass in the left lower lung field with mediastinal adenopathy. There was a pulmonary embolus in the posterior basal segment of the left pulmonary artery, originating from the location of the mass. The CT was also significant for an intraluminal polypoid filling defect in the aortic arch with multiple small splenic and left renal infarcts, suggestive of a peripherally embolizing aortic thrombus. The patient was started on anticoagulation with low molecular weight heparin and was recommended to have an aortic arch stent placed to prevent further embolization of the thrombus. However, the patient decided against the procedure. Further biopsy and staging workup of the left lung mass revealed metastatic squamous cell carcinoma. The patient decided against palliative chemotherapy and opted for hospice care. DISCUSSION: Thoracic aortic mural thrombus is the result of disturbances in the Virchow's triad, ie, stasis, hypercoagulability, and endothelial dysfunction. The patient's smoking history, extensive atherosclerosis, malignancy, and left ventricular dysfunction were likely contributing factors. Aortic thrombi are prone to peripheral embolization to sites such as the spleen, kidneys, small bowel, and lower extremities(2). Early diagnosis and prompt management with anticoagulation are key. Endovascular repair with endograft stents is a novel modality of treatment with higher safety, patient acceptability, and a lower rate of peripheral embolization(3). CONCLUSIONS: Thoracic aortic thrombi are an initially silent rare disease condition with potentially fatal complications. Prompt management with anticoagulation and possible endovascular treatment is warranted. REFERENCE #1: Yang P, Li Y, Huang Y, Lu C, Liang W, Hu J. A giant floating thrombus in the ascending aorta: a case report. BMC Surg. 2020 Dec 9;20(1):321 REFERENCE #2: Bukharovich IF, Wever-Pinzon O, Shah A, Todd G, Chaudhry FA, Sherrid MV. Arterial Embolism Caused by Large Mobile Aortic Thrombus in the Absence of Atherosclerosis, Associated with Iron Deficiency Anemia. Echocardiogr Mt Kisco N. 2012 Mar;29(3):369–72. REFERENCE #3: Jamjoom R, Zagzoog MM, Sait S. Outcome of Endovascular Approach for Management of Thoracic Aortic Thrombus. Ann Vasc Surg. 2019 Aug 1;59:307.e7-307.e12. DISCLOSURES: No relevant relationships by Amjad Basheer, source=Web Response No relevant relationships by Rana Prathap Padappayil, source=Web Response No relevant relationships by DISHANT SHAH, source=Web Response No relevant relationships by vinit singh, source=Web Response No relevant relationships by Raghu Tiperneni, source=Web Response

Disseminated Nocardia in an Immunocompetent Host

A 44-year-old man with no medical comorbidities presented with recurrent inferior vena cava thrombosis and several months of fever, headache, and weight loss. Positron emission tomography–computed tomography was performed, which revealed a 1.5-cm fluorodeoxyglucose avid left lung mass and hypermetabolic soft tissue masses in bilateral inguinal regions (Figure 1). He underwent computed tomography–guided biopsy of the lung and left inguinal masses. Histopathology found clumps of filamentous branching bacilli, consistent with Nocardia (Supplemental Figure, available online at http://www.mayoclinicproceedings.org). Broad-range bacterial polymerase chain reaction (16s rRNA detection) returned positive for Nocardia paucivorans. Subsequent brain magnetic resonance imaging exhibited innumerable brain abscesses (Figure 2). Immunodeficiency work-up was performed and was unremarkable. He began therapy with intravenous trimethoprim-sulfamethoxazole, amikacin, and imipenem.Figure 2Abscesses with surrounding vasogenic edema on T2-weighted fluid-attenuated inversion recovery magnetic resonance imaging.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Nocardia is a filamentous, Gram-positive, partially acid-fast bacterium that is ubiquitous in the environment.1Lerner P.I. Nocardiosis.Clin Infect Dis. 1996; 22: 891-903Crossref PubMed Scopus (499) Google Scholar It is capable of disseminating to almost any organ, but it has a predilection for the lungs and brain. It also has a tendency to recur. Disseminated infection is more common in immunocompromised hosts, but approximately one-third of infections occur in patients who are immunocompetent.2Corti M.E. Villafañe-Fioti M.F. Nocardiosis: a review.Int J Infect Dis. 2003; 7: 243-250Abstract Full Text PDF PubMed Scopus (170) Google Scholar, 3Dominguez D.C. Antony S.J. Actinomyces and Nocardia infections in immunocompromised and nonimmunocompromised patients.J Natl Med Assoc. 1999; 91: 35-39PubMed Google Scholar, 4Sorrell T.C. Mitchell D.H. Iredell J.R. Chen S.C.-A. Nocardia species.in: Bennett J.E. Dolin R. Blaser M.J. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 8th ed. Elsevier, Philadelphia, PA2015: 2853-2863Crossref Scopus (16) Google Scholar Treatment for disseminated disease requires induction with intravenous multidrug therapy. Trimethoprim-sulfamethoxazole forms the backbone of induction therapy and is combined with one or both of amikacin and imipenem. Imipenem is required if there is central nervous system involvement. Treatment should be tailored based on susceptibilities, if available. After induction, patients may be transitioned to dual oral therapy with trimethoprim-sulfamethoxazole and either minocycline or amoxicillin-clavulanate. A total of 12 months of therapy is typical for immunocompromised patients and those with central nervous system involvement.4Sorrell T.C. Mitchell D.H. Iredell J.R. Chen S.C.-A. Nocardia species.in: Bennett J.E. Dolin R. Blaser M.J. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 8th ed. Elsevier, Philadelphia, PA2015: 2853-2863Crossref Scopus (16) Google Scholar We acknowledge and thank Julie Guerin, MD, and Ayse Tuba Kendi, MD, for interpreting and providing the images of the brain magnetic resonance imaging and positron emission tomography–computed tomography, respectively.